PRESCRIBING
Key Messages in prescribing for stoma care Jeanette Fake and Gill Skipper
T
© 2014 MA Healthcare Ltd
he introduction of local clinical commissioning groups (CCGs), represented a new era in health care, and also the ideal opportunity for the authors to promote awareness of their service and target the message about appropriate stoma prescribing. The stoma service needed to explore whether local surgeries were receiving the input they required, and whether the authors could improve on any aspect, such as support and advice for pharmacists, and for the prescribers. The Norfolk and Waveney Commissioning Support Unit was keen to target a number of areas with a view to ensuring value for money and to ensure service needs were being met. The concept of ‘Key Messages’ was developed (Table 1, Table 2, Table 3 and Table 4)—an idea that would give basic information to GPs, key prescribers, and dispensaries regarding prescribing of stoma care appliances and accessories. The authors worked closely with Debbie Craven (Prescribing & Medicines Management Team) to develop a flow chart regarding accessory use (Table 2) and to determine a list of what was deemed normal or excessive use of products. The Key Messages are intended to be used purely as a guideline and throughout remind the prescriber that each patient is individual, and both needs and requirements can, and do vary. The guidelines should improve awareness of the cost effectiveness of stoma appliances and appropriate use of accessories, and alert the appropriate prescriber to over use or over ordering. A priority was ensuring that local prescribers were using the authors’ expertise and knowledge both of the patient and the products. The authors also wanted to enhance communication with the GP so that care of the stoma patients became a joint effort, with both the stoma team and GP fully aware of the patients’ needs. Research has suggested that patients who have access to a clinical nurse in stoma care show greater satisfaction, better stoma knowledge and have fewer problems (Elcoat et al, 2010). The introduction of Equity and Excellence – liberating the NHS (Department of Health (DH), 2010) emphasises the need for services to be less insular and fragmented. Working within a specialised area can mean that as a professional it is all too easy to become blinkered to issues that do not relate directly to your field of expertise. Being ‘politically’ and Jeanette Fake, Colorectal Specialist Nurse; Gill Skipper, Stoma Care Specialist Nurse, The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust Accepted for publication: September 2014
British Journal of Nursing, 2014, Vol 23, No 17
Abstract
With £248 million spent on stoma appliances and accessories throughout England in 2013 (Health and Social Care Information Centre, 2014) value for money and control of this process is seen to be of high priority. This does not have to mean restricted access of appliances, rather that there is appropriate usage of the budget. This article looks at how the stoma care team collaborated with the local clinical commissioning group (CCG) in order for the local surgeries to gain a better understanding of the needs of their local stoma care population. It was hoped that this would facilitate further control in the ordering (by the patient or GP) of stoma care products. The Key Messages produced are to be used as a tool to aid cost-effective stoma care. Key words: Stoma care ■ Appropriate prescribing ■ Cost reduction ■ Key Messages ‘pharmaceutically’ aware is necessary as NHS growth money comes to an end and commissioners look to make savings and secure value for money. Alongside excelling at patient care, it is essential to actively promote the cost effectiveness and social and economic benefit of the work of the stoma nurse (Black, 2010).
Accessory products Ensuring that accessory products, such as skin protectors, pastes, powders, creams, support belts/girdles are prescribed appropriately can lead to a reduction in re-admission (North, 2014). Problems such as obstruction caused by parastomal hernia, or major skin problems due to leakage can be avoided, reducing costs further. If the correct support appliance is worn by the patient, the need for further abdominal surgery can be avoided, and use of the correct skin protector ensures the patient does not have to use excessive amounts of bags because of lack of adherence, or the need to refer to a dermatology specialist. Since accessory products have become more readily available, and the use of the internet has grown, their use and cost has escalated, as patients are able to request samples and then add them to their list of items to be prescribed. Over the last 12 years the amount spent on these products has grown from £12 724 000 in 2000 to £53 114 000 in 2012 (Black, 2013). This is naturally causing great concern for the CCGs and in many areas formularies are being devised of products that may be used to try and keep costs down. Formularies mean that only certain products/brands of product can
S17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Table 1. Key Message: basic stoma appliance products Recommended monthly amount 1 piece
2 pieces
Comment
Level for re-order
Colostomy
Three boxes of closed bags (90)
30 left
Ileostomy
One box of drainable bags (30)
An extra box for spares
15 left
Urostomy
One box of 30 bags (30)
An extra box for spares
15 left
Colostomy
Three boxes of closed bags (90) One box of drainable bags (30)
Will need 2-3 boxes of flanges (usually in fives)
30 left
Ileostomy Urostomy
One box of 30 bags (30)
15 left 15 left
Notes: 1. Some ostomists need more ileostomy bags if they prefer to use midi bags during the day and maxi bags at night (mainly youngsters for body image). 2. More than the recommended amounts may be ordered under the following circumstances; suffering with gastrointestinal symptoms, dietary problems or skin issues, i.e. ulceration or undergoing chemotherapy.
Box 1: Key Message: further information: one- or twopiece systems
Box 2: Key Message:What do prescribers need to do in practice?
■■ One-piece
■■ Do
Key Message: useful information ■■ Stoma irrigating: use of warm tap water (bottled if abroad), through an irrigation appliance is encouraged (if appropriate) which helps colostomists to gain control as it is performed daily/on alternate days at the same time of day. This also means the patient can then wear a mini bag/stoma cap as the intention is for no faecal output until irrigation takes place again. An additional advantage of this is that fewer bags are used ■■ Convex pouching system products are normally in boxes of ten so the patient may be ordering more boxes but the stock level of bags will be the same ■■ Some appliance wholesalers may offer night bag stands and other products, i.e. mattress protective covers, on request; some free of charge but others may charge the patient ■■ Some colostomists prefer drainable bags and some ileostomists prefer closed bags; they should take guidance from a stoma care nurse.
be prescribed. However, it is essential to understand the importance of the use of accessories, which for some patients are used out of necessity not choice. Many accessories prevent the occurrence of common stoma-related problems, e.g. skin erythema, skin tears, peristomal hernias, and even readmission (Black, 2013), so removing patient choice is not an option, ensuring appropriate choice and use is, and this is what the team wanted to achieve. The intervention’s Key Messages mentioned above signaled a need for the stoma care team at the Queen Elizabeth Hospital (QEH) in King’s Lynn to review practice. The team needed
S18
not issue retrospective prescriptions for stoma products, unless first order ■■ Do not accept patient requests for new products without checking with the stoma care nurse ■■ Do check all requests are needed and are appropriate—see information in Table 1 and Box 5 ■■ Prescribe appropriate quantities for 1 month’s supply of appliances ■■ Contact stoma care nurse if expert advice required
to determine that they were ensuring value for the patients. One of the areas needing attention was whether GPs actually understood what they were prescribing. It was also necessary to determine whether any areas of savings could be focused on, but still ensuring that the patient had choice and freedom to choose an appropriate stoma appliance they felt secure and comfortable using. The availability of information regarding stoma care and appliances on the internet is immense, and although some is of great use, some of it has safety implications if patients are able to request samples of products that are not appropriate for them. It was essential to try and find a safety net so that patients were not adding inappropriate items to their prescriptions, not only because of the cost implications, but also because of patient safety. With the introduction of Annual User Reviews (AURs), which can be carried out by local pharmacists, or a nurse sponsored by a delivery company, the authors felt that a regular review by the stoma care team would be appropriate and preempt any problems. This review would also be more impartial as it would not be carried out by a companysponsored nurse and also would be performed by a nurse that knows the patient.
Initiating the necessary changes There followed a meeting with the local CCG key prescribers and a GP representing each local surgery within the local CCG umbrella. This was the team’s chance to sell the service and present the Key Messages to see if this would be of any use to the local teams. With some amount of trepidation the authors presented the Key Messages and held a question and answer session about the work of the stoma care team.The authors also
© 2014 MA Healthcare Ltd
systems have a seal and pouch as one item and are easy to apply and are not bulky on the patient’s abdomen. This system has either a pre-cut opening or an opening that can be cut to fit the stoma ■■ Two-piece systems have a base plate that sticks to the skin onto which the patient can clip the pouch. Usually, the base plate is changed every 3 days (less irritating to skin as changed less often than one-piece system), whereas the pouch is changed on average two or three times a day. This system has either a pre-cut opening or an opening that can be cut to fit the stoma.
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Colostomy (Closed pouches usually changed 1-3 x daily)
Ileostomy (Open-ended drainage)
Does your patient use more than 30-90 pouches per month? (1 piece) or Does your patient use more than 15 base plates and 30-90 pouches per month? (2 pieces)
Urostomy (Pouches with tap)
Does your patient use more than 30 pouches per month? (1 piece) or Does your patient use more than 15 base plates and 30 pouches per month? (2 pieces)
No
Yes
No
Patient may be experiencing problems and should be referred to the stoma care nurse (if available) for reassessment
Does your patient use more than two stoma accessories? (See stoma accessories Key Messages - Bulletin 21)
No No action required
Yes Patient may be experiencing problems and should be referred to the stoma care nurse (if available) for reassessment
Figure 1. Key Message: which system does your patient have?
■■ Review
your stoma patients’ accessories prescribing against the recommendations (Table 2) and the flow chart below: ■■ Ensure there are only ‘routinely recommended’ accessories on repeat ■■ Prescribe appropriate quantities on repeat ■■ Do not add any occasionally required accessory products on repeat, unless recommended by the stoma care nurse ■■ Do not routinely prescribe any bag covers or deodorants ■■ Ensure patients do not over order their accessories—please see flow chart (Figure 2) ■■ Refer back to the stoma care nurse for review if over ordering
offered to audit their local surgeries to ensure patient ordering was appropriate.The meeting was a huge success. As stoma care nurses the authors were surprised at how much information was required and that there was such a variance in knowledge of stoma care throughout the local surgeries. GPs were also very much unaware of what a stoma nurse did, and indeed what knowledge and skills could be offered, many thinking that the stoma nurse work entailed merely changing patient’s bags and teaching patients how to do it themselves.
S20
Outcome/s following the meeting Since this meeting, many of the authors’ local surgeries have approached the team to audit their stoma patients’ prescribing patterns in order to ensure appropriate ordering, but also meaning that financial savings can follow if discrepancies are found. While auditing the authors found that some surgeries were listing all skin-protector prescriptions under the heading of stoma care and when looking in more detail at the detail of these patients, it was found that up to half of them were using skin protector or barrier cream for reasons other than stoma care, and so the budget for stoma accessories was less than originally thought. Because the lead prescribers from local surgeries have now put a name to a face, they approach the team much more regularly about problematic patients. It is worth contacting your local surgeries from time to time and making sure that they are aware you are out there, working on their behalf with their patients, and can offer the time to review patients and give up-to-date and expert advice. A monthly spreadsheet of orders from the delivery service used by the majority of patients has also been arranged so that patterns of ordering can be monitored. The delivery service now phones for confirmation so that additional/extra items are not added to patient orders without assessment/ agreement by the stoma team; the safety net that the authors were looking for. New or additional items are not sent out
© 2014 MA Healthcare Ltd
Box 3: Key Message: what do prescribers need to do in practice?
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Table 2. Key Message: Types of stoma accessory products Product types
Product forms
Indications
Other information
To reduce skin stripping
One to two cans/box of 30 bags Wipes can be used instead of spray, max one wipe per bag
For urostomies only
One night bag per week or if single use, one night bag per urostomy bag
To protect the skin around the stoma To soothe and protect broken or sore skin
Max one wipe per bag Max one can per box of 30 bags Other forms: usage will depend on need, check with patient to avoid over ordering/wastage. Only to be prescribed after discussion with the stoma care nurse
Routinely recommended Adhesive removers
Sprays and wipes
Night drainage bags Skin protectors
Aerosols, creams, lotions, pastes, powders, wafers, and wipes
Occasionally recommended Adhesives
Flange extenders
To allow the pouch to stick better
Often used for patients with a para-stomal hernia
Belts/underwear
Panty girdles and belts
To aid prevention of hernias and offer abdominal muscle support
Max three belts/year Max three girdles/year Max six pairs briefs or boxers/year
Discharge-solidifying agents
Absorbent strips, gel capsules/ tablets and sachets
For use only when faeces are watery
One box per box of 30 bags
Irrigation/washout appliances
Irrigation sets and accessories
For colostomy irrigation as advised by the stoma care nurse
One set every 6 months. Use with warm tap water (or bottled if abroad)
Skin fillers
Pastes, seals and washers
To provide a flat surface to apply the appliance
Used if stoma is recessed or there are creases, folds, etc.
Bag covers
Cloth fibre or non woven
To cover the pouch
They can be washed and reused many times
Deodorants
Drops, sachets or sprays
To mask the odour
Various scents. Possibly only for existing patients
Box 4. Key Message: Medicines required for stoma management There are a growing number of stoma patients which can often pose challenges around prescribing. The aim of this Key Message document is to provide relevant information to encourage appropriate prescribing and support for stoma patients. ■■ Some
ileostomy patients can experience occasional problematic, high-volume liquid stomal output, which can cause dehydration, potential renal impairment, body image problems and increased product usage ■■ Anti-motility agents (loperamide or codeine), can be used to treat this. They slow down gastrointestinal transit time, allowing more water to be absorbed thus thickening and decreasing the stoma output ■■ Loperamide is preferred as it is not sedative and not addictive or open to abuse ■■ Patients are usually able to self-manage ad hoc dosing according to requirements ■■ Longer-term use with higher doses may be necessary if patients have a ‘short-bowel’ ■■ Loperamide should be taken half an hour before food for maximum effect ■■ If not effective initially i.e. patient still has high-volume output, loperamide capsules can be opened and dissolved in squash/water before taking ■■ Some stoma patients experience constipation. With the exception of ileostomy patients, an increase in fluid intake or dietary fibre (wherever possible) should be tried first before initiating bulk-forming or osmotic laxatives. Medicines required for stoma management Drug
Dose
Loperamide 2 mg capsules
2 mg to 4 mg four times a day as required (max 16 mg daily)
Codeine phosphate 15 mg and 30 mg tablets
15 mg to 30 mg four times a day (max 240 mg daily)
S22
without the verbal consent of the appropriate stoma nurse. This has led to a reduction in stockpiling but also a stop to inappropriate/incorrect use of accessories. Key Messages are divided into several sections. First, stoma products (Table 1). This gives an overview of how many products a patient is likely to use per month, reiterating that of course each patient is individual and must be assessed as such. Table 2 introduces accessories and explains their use, and average useage per person. It also explains that some accessories are used routinely and others are for occasional use. This will help the pharmacist to regulate ordering of ‘occasional use’ items. The delivery company used by the QEH Kings Lynn NHS Foundation Trust has an agreement with the authors to always phone before adding extras to orders, which means the authors have been able to considerably reduce usage of accessories in general. Figure 1 is a flow chart that indicates whether referral back to the stoma care nurse is required to ensure that the patient is not developing problems, such as excessive changing of bags owing to high output, or skin excoriation requiring excessive use of skin protector/adhesive remover. It is a simple flow chart, and each patient needs to be assessed individually.There are always going to be patients who require more stock than others because of their other co-morbidities/skin problems etc., but this gives an indication that, for example, an order of 6 tubes of paste per month requires monitoring as perhaps a seal/convex seal may give better adhesion and would be a more cost-effective way of treating skin dips or creases that require extra adhesion.
© 2014 MA Healthcare Ltd
Not routinely recommended
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Use of accessory products Adhesive remover spray/wipes
Skin protectors
Does your patient use more than one wipe per bag or more than one can of spray per box of 30 bags?
No Request appropriate
Yes
Does your patient use more than one wipe per bag or more than one can of spray per box of 30 bags?
No Request appropriate
Yes
Paste seals
Does your patient use more than one seal per bag or more than one tube per box of 30 bags?
No Request appropriate
Yes
Patient may be experiencing problems Refer to stoma care nurse for assistance Figure 2. Use of accessory products: this is a guideline only, some patients for example may require more than 1 tube of paste per 30 bags, but this would need to be appropriately reviewed by the stoma care nurse
Table 3. Key Message: medicines to use with care or avoid in stoma patients Drug
Reason
Antacids
Magnesium salts may cause diarrhoea. Aluminium salts may cause constipation
Antibiotics
Caution as may cause diarrhoea
Digoxin
Patients susceptible to hypokalaemia should be monitored closely; consider supplements or potassiumsparing diuretics
Diuretics
Patients may become dehydrated. Caution with ileostomy patients? may become potassium depleted
Enteric-coated (EC) and modified-release (MR) preparations
May be unsuitable, particularly in ileostomy patients, as there may not be sufficient release of the active ingredient therefore consider non-EC/MR preparations first-choice
Iron. i.e., ferrous fumarate, sulphate
May cause diarrhoea in ileostomy patients or constipation in colostomy patients. Stools may be black; important to reassure/warn patients
Laxative enemas and washouts
Avoid in ileostomy patients; may cause rapid and severe loss of water/electrolytes
Nicorandil
Anal and peristomal ulceration; related to inflammatory disease
Opioid analgesics
Caution as may cause troublesome constipation
Proton pump inhibitors
May cause diarrhoea
Routes of administration points of note Please be aware that it may not be appropriate to use per rectum route for stoma patients, please check clinical records Medication cannot be administered via the stoma
S24
products in the vast stoma care market, and so they need the expert guidance of a readily available and approachable stoma-care team. Use of a simple flow chart can indicate if a patient is perhaps in need of review. Regular review of patient need prevents complications arising and prevents over-use, incorrect usage and even readmission. All too often nursing as a profession is reluctant to promote their usefulness, it is time to tell people what the nursing profession is worth and how cost effective it can be.
Conclusion As a result of use of the Key Messages, the majority of surgeries within the authors’ remit have since requested an audit of their stoma prescribing patterns. This has meant that the authors have been able to go into each surgery and discuss individual patient’s requirements in a way that ensures that the GP and pharmacist understand what the patient needs and why, quantities, what is essential and what can be ordered on an ‘as-required’ basis. Naturally, this has meant an increased workload but this can be done on a yearly basis so that any discrepancies can be picked up sooner. As mentioned previously there were also a number of cases of patients who required skin protectors for dermatological or incontinence problems rather than stoma care, but who had been accredited to the stoma care budget. Awareness of this discrepancy has helped surgeries to better align their budgets. Communication between the stoma team and local GPs has improved in that they are much more likely to bleep the team and ask for advice. It has also meant an increase in telephone calls from the delivery service regarding addition of accessories/products, but the stoma team have been able to ensure that inappropriate items have not been added that may have caused either damage to the patient’s skin or extra cost with no benefit. The team also gets a monthly list of what each patient is ordering; this highlights any excessive
© 2014 MA Healthcare Ltd
Table 3 was added as many dispensary assistants, district nurses etc., were unaware of some of the problems caused by the more commonplace medications and their effect on stoma output, so it was thought that a simple chart may be of use. Again this is offered as an ‘easy use’ guideline only. All of this work is relevant for any hospital with a stoma care input. GPs are unable to keep up to date with current
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
PRESCRIBING ordering owing to leakages/inadequate adhesion of pouches or inappropriate stockpiling. The relationship between the stoma care team and the medicines management team, and also with local pharmacists and dispensaries has improved greatly, in that they feel more able to contact the team and approach them for advice. Excess stock returned to the team after patients have either had their stoma reversed, or if a patient has died, has decreased dramatically as patients have a better understanding of the cost involved in stockpiling. The review is not only about money, but also about evidence-based practice and achieving the best care for the patient, and hopefully the easy-to-use Key Messages will also achieve the best for each BJN individual patient.
KEY POINTS n The
‘Key Messages’ in this article are a guideline/tool only and each individual needs to be assessed on their own merit and has individual needs
n Taking
control of patient ordering ensures value for money for the service but also appropriate and correct care for the patient
n The
introduction of clinical commissioning groups is a new era and an opportunity for all stoma care services to promote their contribution to patient care and to establish new channels for multidisciplinary patient review
London. http://tinyurl.com/mk4m6hd (accessed 15th September 2014)
Elcoat C, Katte C, Morrisroe J et al (2010) High Impact Actions for Stoma Care. Colopast UK Ltd, Peterborough. http://tinyurl.com/nu5lchx (accessed 11 September 2014)
Conflict of interest: none Black P (2010) Professional promotion: Ensuring the value of stoma care services is recognized. Gastrointestinal Nursing 8(1): 27-30 Black P (2013) The role of accessory products in patients with a stoma. Br J Nurs 22(5): S24 Department of Health (2010) Equity and Excellence – liberating the NHS. DH,
Health and Social Care Information Centre (2014) Prescription Cost Analysis England 2013: Prescription items dispensed in the community in England and listed alphabetically within chemical entity by therapeutic class. 3 April. http://tinyurl.com/lnjysdh (accessed 17 September 2014) North J (2014) Early intervention, parastomal hernia and quality of life: a research study. Br J Nurs 23(5): S14-8
Orthopaedic Trauma Fares Haddad, Sam Oussedik, Rahul Patel n Designed to cover the basics of managing common orthopaedic and musculoskeletal injuries n Outlines a series of orthopaedic, musculoskeletal and trauma competencies
Orthopaedic Trauma: A Systematic Guide
n Intended to aid those involved in the initial assessment and management of patients to make the necessary fundamental and critical decisions
Edited by Fares Haddad, Sam Ous
sedik and Rahul Patel
n Specifically aimed at junior doctors and medical students n Chapters are based around a series published in the British Journal of Hospital Medicine; they are written by junior doctors but supervised by senior experts
© 2014 MA Healthcare Ltd
ISBN-13: 978-1-85642-248-2; ISBN-10: 1-85642-248-8; 234 x 156 mm; paperback; 260 pages; publication 2008; £24.99
Order your copies by visiting
www.quaybooks.co.uk
or call our Hotline
+44(0)1722 716 935
OrthopaedicCover.indd 1 30/3/07 14:50:45
British Journal of Nursing, 2014, Vol 23, No 17
S25
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key Messages in prescribing for stoma care Jeanette Fake and Gill Skipper
T
© 2014 MA Healthcare Ltd
he introduction of local clinical commissioning groups (CCGs), represented a new era in health care, and also the ideal opportunity for the authors to promote awareness of their service and target the message about appropriate stoma prescribing. The stoma service needed to explore whether local surgeries were receiving the input they required, and whether the authors could improve on any aspect, such as support and advice for pharmacists, and for the prescribers. The Norfolk and Waveney Commissioning Support Unit was keen to target a number of areas with a view to ensuring value for money and to ensure service needs were being met. The concept of ‘Key Messages’ was developed (Table 1, Table 2, Table 3 and Table 4)—an idea that would give basic information to GPs, key prescribers, and dispensaries regarding prescribing of stoma care appliances and accessories. The authors worked closely with Debbie Craven (Prescribing & Medicines Management Team) to develop a flow chart regarding accessory use (Table 2) and to determine a list of what was deemed normal or excessive use of products. The Key Messages are intended to be used purely as a guideline and throughout remind the prescriber that each patient is individual, and both needs and requirements can, and do vary. The guidelines should improve awareness of the cost effectiveness of stoma appliances and appropriate use of accessories, and alert the appropriate prescriber to over use or over ordering. A priority was ensuring that local prescribers were using the authors’ expertise and knowledge both of the patient and the products. The authors also wanted to enhance communication with the GP so that care of the stoma patients became a joint effort, with both the stoma team and GP fully aware of the patients’ needs. Research has suggested that patients who have access to a clinical nurse in stoma care show greater satisfaction, better stoma knowledge and have fewer problems (Elcoat et al, 2010). The introduction of Equity and Excellence – liberating the NHS (Department of Health (DH), 2010) emphasises the need for services to be less insular and fragmented. Working within a specialised area can mean that as a professional it is all too easy to become blinkered to issues that do not relate directly to your field of expertise. Being ‘politically’ and Jeanette Fake, Colorectal Specialist Nurse; Gill Skipper, Stoma Care Specialist Nurse, The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust Accepted for publication: September 2014
British Journal of Nursing, 2014, Vol 23, No 17
Abstract
With £248 million spent on stoma appliances and accessories throughout England in 2013 (Health and Social Care Information Centre, 2014) value for money and control of this process is seen to be of high priority. This does not have to mean restricted access of appliances, rather that there is appropriate usage of the budget. This article looks at how the stoma care team collaborated with the local clinical commissioning group (CCG) in order for the local surgeries to gain a better understanding of the needs of their local stoma care population. It was hoped that this would facilitate further control in the ordering (by the patient or GP) of stoma care products. The Key Messages produced are to be used as a tool to aid cost-effective stoma care. Key words: Stoma care ■ Appropriate prescribing ■ Cost reduction ■ Key Messages ‘pharmaceutically’ aware is necessary as NHS growth money comes to an end and commissioners look to make savings and secure value for money. Alongside excelling at patient care, it is essential to actively promote the cost effectiveness and social and economic benefit of the work of the stoma nurse (Black, 2010).
Accessory products Ensuring that accessory products, such as skin protectors, pastes, powders, creams, support belts/girdles are prescribed appropriately can lead to a reduction in re-admission (North, 2014). Problems such as obstruction caused by parastomal hernia, or major skin problems due to leakage can be avoided, reducing costs further. If the correct support appliance is worn by the patient, the need for further abdominal surgery can be avoided, and use of the correct skin protector ensures the patient does not have to use excessive amounts of bags because of lack of adherence, or the need to refer to a dermatology specialist. Since accessory products have become more readily available, and the use of the internet has grown, their use and cost has escalated, as patients are able to request samples and then add them to their list of items to be prescribed. Over the last 12 years the amount spent on these products has grown from £12 724 000 in 2000 to £53 114 000 in 2012 (Black, 2013). This is naturally causing great concern for the CCGs and in many areas formularies are being devised of products that may be used to try and keep costs down. Formularies mean that only certain products/brands of product can
S17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Table 1. Key Message: basic stoma appliance products Recommended monthly amount 1 piece
2 pieces
Comment
Level for re-order
Colostomy
Three boxes of closed bags (90)
30 left
Ileostomy
One box of drainable bags (30)
An extra box for spares
15 left
Urostomy
One box of 30 bags (30)
An extra box for spares
15 left
Colostomy
Three boxes of closed bags (90) One box of drainable bags (30)
Will need 2-3 boxes of flanges (usually in fives)
30 left
Ileostomy Urostomy
One box of 30 bags (30)
15 left 15 left
Notes: 1. Some ostomists need more ileostomy bags if they prefer to use midi bags during the day and maxi bags at night (mainly youngsters for body image). 2. More than the recommended amounts may be ordered under the following circumstances; suffering with gastrointestinal symptoms, dietary problems or skin issues, i.e. ulceration or undergoing chemotherapy.
Box 1: Key Message: further information: one- or twopiece systems
Box 2: Key Message:What do prescribers need to do in practice?
■■ One-piece
■■ Do
Key Message: useful information ■■ Stoma irrigating: use of warm tap water (bottled if abroad), through an irrigation appliance is encouraged (if appropriate) which helps colostomists to gain control as it is performed daily/on alternate days at the same time of day. This also means the patient can then wear a mini bag/stoma cap as the intention is for no faecal output until irrigation takes place again. An additional advantage of this is that fewer bags are used ■■ Convex pouching system products are normally in boxes of ten so the patient may be ordering more boxes but the stock level of bags will be the same ■■ Some appliance wholesalers may offer night bag stands and other products, i.e. mattress protective covers, on request; some free of charge but others may charge the patient ■■ Some colostomists prefer drainable bags and some ileostomists prefer closed bags; they should take guidance from a stoma care nurse.
be prescribed. However, it is essential to understand the importance of the use of accessories, which for some patients are used out of necessity not choice. Many accessories prevent the occurrence of common stoma-related problems, e.g. skin erythema, skin tears, peristomal hernias, and even readmission (Black, 2013), so removing patient choice is not an option, ensuring appropriate choice and use is, and this is what the team wanted to achieve. The intervention’s Key Messages mentioned above signaled a need for the stoma care team at the Queen Elizabeth Hospital (QEH) in King’s Lynn to review practice. The team needed
S18
not issue retrospective prescriptions for stoma products, unless first order ■■ Do not accept patient requests for new products without checking with the stoma care nurse ■■ Do check all requests are needed and are appropriate—see information in Table 1 and Box 5 ■■ Prescribe appropriate quantities for 1 month’s supply of appliances ■■ Contact stoma care nurse if expert advice required
to determine that they were ensuring value for the patients. One of the areas needing attention was whether GPs actually understood what they were prescribing. It was also necessary to determine whether any areas of savings could be focused on, but still ensuring that the patient had choice and freedom to choose an appropriate stoma appliance they felt secure and comfortable using. The availability of information regarding stoma care and appliances on the internet is immense, and although some is of great use, some of it has safety implications if patients are able to request samples of products that are not appropriate for them. It was essential to try and find a safety net so that patients were not adding inappropriate items to their prescriptions, not only because of the cost implications, but also because of patient safety. With the introduction of Annual User Reviews (AURs), which can be carried out by local pharmacists, or a nurse sponsored by a delivery company, the authors felt that a regular review by the stoma care team would be appropriate and preempt any problems. This review would also be more impartial as it would not be carried out by a companysponsored nurse and also would be performed by a nurse that knows the patient.
Initiating the necessary changes There followed a meeting with the local CCG key prescribers and a GP representing each local surgery within the local CCG umbrella. This was the team’s chance to sell the service and present the Key Messages to see if this would be of any use to the local teams. With some amount of trepidation the authors presented the Key Messages and held a question and answer session about the work of the stoma care team.The authors also
© 2014 MA Healthcare Ltd
systems have a seal and pouch as one item and are easy to apply and are not bulky on the patient’s abdomen. This system has either a pre-cut opening or an opening that can be cut to fit the stoma ■■ Two-piece systems have a base plate that sticks to the skin onto which the patient can clip the pouch. Usually, the base plate is changed every 3 days (less irritating to skin as changed less often than one-piece system), whereas the pouch is changed on average two or three times a day. This system has either a pre-cut opening or an opening that can be cut to fit the stoma.
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Colostomy (Closed pouches usually changed 1-3 x daily)
Ileostomy (Open-ended drainage)
Does your patient use more than 30-90 pouches per month? (1 piece) or Does your patient use more than 15 base plates and 30-90 pouches per month? (2 pieces)
Urostomy (Pouches with tap)
Does your patient use more than 30 pouches per month? (1 piece) or Does your patient use more than 15 base plates and 30 pouches per month? (2 pieces)
No
Yes
No
Patient may be experiencing problems and should be referred to the stoma care nurse (if available) for reassessment
Does your patient use more than two stoma accessories? (See stoma accessories Key Messages - Bulletin 21)
No No action required
Yes Patient may be experiencing problems and should be referred to the stoma care nurse (if available) for reassessment
Figure 1. Key Message: which system does your patient have?
■■ Review
your stoma patients’ accessories prescribing against the recommendations (Table 2) and the flow chart below: ■■ Ensure there are only ‘routinely recommended’ accessories on repeat ■■ Prescribe appropriate quantities on repeat ■■ Do not add any occasionally required accessory products on repeat, unless recommended by the stoma care nurse ■■ Do not routinely prescribe any bag covers or deodorants ■■ Ensure patients do not over order their accessories—please see flow chart (Figure 2) ■■ Refer back to the stoma care nurse for review if over ordering
offered to audit their local surgeries to ensure patient ordering was appropriate.The meeting was a huge success. As stoma care nurses the authors were surprised at how much information was required and that there was such a variance in knowledge of stoma care throughout the local surgeries. GPs were also very much unaware of what a stoma nurse did, and indeed what knowledge and skills could be offered, many thinking that the stoma nurse work entailed merely changing patient’s bags and teaching patients how to do it themselves.
S20
Outcome/s following the meeting Since this meeting, many of the authors’ local surgeries have approached the team to audit their stoma patients’ prescribing patterns in order to ensure appropriate ordering, but also meaning that financial savings can follow if discrepancies are found. While auditing the authors found that some surgeries were listing all skin-protector prescriptions under the heading of stoma care and when looking in more detail at the detail of these patients, it was found that up to half of them were using skin protector or barrier cream for reasons other than stoma care, and so the budget for stoma accessories was less than originally thought. Because the lead prescribers from local surgeries have now put a name to a face, they approach the team much more regularly about problematic patients. It is worth contacting your local surgeries from time to time and making sure that they are aware you are out there, working on their behalf with their patients, and can offer the time to review patients and give up-to-date and expert advice. A monthly spreadsheet of orders from the delivery service used by the majority of patients has also been arranged so that patterns of ordering can be monitored. The delivery service now phones for confirmation so that additional/extra items are not added to patient orders without assessment/ agreement by the stoma team; the safety net that the authors were looking for. New or additional items are not sent out
© 2014 MA Healthcare Ltd
Box 3: Key Message: what do prescribers need to do in practice?
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Table 2. Key Message: Types of stoma accessory products Product types
Product forms
Indications
Other information
To reduce skin stripping
One to two cans/box of 30 bags Wipes can be used instead of spray, max one wipe per bag
For urostomies only
One night bag per week or if single use, one night bag per urostomy bag
To protect the skin around the stoma To soothe and protect broken or sore skin
Max one wipe per bag Max one can per box of 30 bags Other forms: usage will depend on need, check with patient to avoid over ordering/wastage. Only to be prescribed after discussion with the stoma care nurse
Routinely recommended Adhesive removers
Sprays and wipes
Night drainage bags Skin protectors
Aerosols, creams, lotions, pastes, powders, wafers, and wipes
Occasionally recommended Adhesives
Flange extenders
To allow the pouch to stick better
Often used for patients with a para-stomal hernia
Belts/underwear
Panty girdles and belts
To aid prevention of hernias and offer abdominal muscle support
Max three belts/year Max three girdles/year Max six pairs briefs or boxers/year
Discharge-solidifying agents
Absorbent strips, gel capsules/ tablets and sachets
For use only when faeces are watery
One box per box of 30 bags
Irrigation/washout appliances
Irrigation sets and accessories
For colostomy irrigation as advised by the stoma care nurse
One set every 6 months. Use with warm tap water (or bottled if abroad)
Skin fillers
Pastes, seals and washers
To provide a flat surface to apply the appliance
Used if stoma is recessed or there are creases, folds, etc.
Bag covers
Cloth fibre or non woven
To cover the pouch
They can be washed and reused many times
Deodorants
Drops, sachets or sprays
To mask the odour
Various scents. Possibly only for existing patients
Box 4. Key Message: Medicines required for stoma management There are a growing number of stoma patients which can often pose challenges around prescribing. The aim of this Key Message document is to provide relevant information to encourage appropriate prescribing and support for stoma patients. ■■ Some
ileostomy patients can experience occasional problematic, high-volume liquid stomal output, which can cause dehydration, potential renal impairment, body image problems and increased product usage ■■ Anti-motility agents (loperamide or codeine), can be used to treat this. They slow down gastrointestinal transit time, allowing more water to be absorbed thus thickening and decreasing the stoma output ■■ Loperamide is preferred as it is not sedative and not addictive or open to abuse ■■ Patients are usually able to self-manage ad hoc dosing according to requirements ■■ Longer-term use with higher doses may be necessary if patients have a ‘short-bowel’ ■■ Loperamide should be taken half an hour before food for maximum effect ■■ If not effective initially i.e. patient still has high-volume output, loperamide capsules can be opened and dissolved in squash/water before taking ■■ Some stoma patients experience constipation. With the exception of ileostomy patients, an increase in fluid intake or dietary fibre (wherever possible) should be tried first before initiating bulk-forming or osmotic laxatives. Medicines required for stoma management Drug
Dose
Loperamide 2 mg capsules
2 mg to 4 mg four times a day as required (max 16 mg daily)
Codeine phosphate 15 mg and 30 mg tablets
15 mg to 30 mg four times a day (max 240 mg daily)
S22
without the verbal consent of the appropriate stoma nurse. This has led to a reduction in stockpiling but also a stop to inappropriate/incorrect use of accessories. Key Messages are divided into several sections. First, stoma products (Table 1). This gives an overview of how many products a patient is likely to use per month, reiterating that of course each patient is individual and must be assessed as such. Table 2 introduces accessories and explains their use, and average useage per person. It also explains that some accessories are used routinely and others are for occasional use. This will help the pharmacist to regulate ordering of ‘occasional use’ items. The delivery company used by the QEH Kings Lynn NHS Foundation Trust has an agreement with the authors to always phone before adding extras to orders, which means the authors have been able to considerably reduce usage of accessories in general. Figure 1 is a flow chart that indicates whether referral back to the stoma care nurse is required to ensure that the patient is not developing problems, such as excessive changing of bags owing to high output, or skin excoriation requiring excessive use of skin protector/adhesive remover. It is a simple flow chart, and each patient needs to be assessed individually.There are always going to be patients who require more stock than others because of their other co-morbidities/skin problems etc., but this gives an indication that, for example, an order of 6 tubes of paste per month requires monitoring as perhaps a seal/convex seal may give better adhesion and would be a more cost-effective way of treating skin dips or creases that require extra adhesion.
© 2014 MA Healthcare Ltd
Not routinely recommended
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
Use of accessory products Adhesive remover spray/wipes
Skin protectors
Does your patient use more than one wipe per bag or more than one can of spray per box of 30 bags?
No Request appropriate
Yes
Does your patient use more than one wipe per bag or more than one can of spray per box of 30 bags?
No Request appropriate
Yes
Paste seals
Does your patient use more than one seal per bag or more than one tube per box of 30 bags?
No Request appropriate
Yes
Patient may be experiencing problems Refer to stoma care nurse for assistance Figure 2. Use of accessory products: this is a guideline only, some patients for example may require more than 1 tube of paste per 30 bags, but this would need to be appropriately reviewed by the stoma care nurse
Table 3. Key Message: medicines to use with care or avoid in stoma patients Drug
Reason
Antacids
Magnesium salts may cause diarrhoea. Aluminium salts may cause constipation
Antibiotics
Caution as may cause diarrhoea
Digoxin
Patients susceptible to hypokalaemia should be monitored closely; consider supplements or potassiumsparing diuretics
Diuretics
Patients may become dehydrated. Caution with ileostomy patients? may become potassium depleted
Enteric-coated (EC) and modified-release (MR) preparations
May be unsuitable, particularly in ileostomy patients, as there may not be sufficient release of the active ingredient therefore consider non-EC/MR preparations first-choice
Iron. i.e., ferrous fumarate, sulphate
May cause diarrhoea in ileostomy patients or constipation in colostomy patients. Stools may be black; important to reassure/warn patients
Laxative enemas and washouts
Avoid in ileostomy patients; may cause rapid and severe loss of water/electrolytes
Nicorandil
Anal and peristomal ulceration; related to inflammatory disease
Opioid analgesics
Caution as may cause troublesome constipation
Proton pump inhibitors
May cause diarrhoea
Routes of administration points of note Please be aware that it may not be appropriate to use per rectum route for stoma patients, please check clinical records Medication cannot be administered via the stoma
S24
products in the vast stoma care market, and so they need the expert guidance of a readily available and approachable stoma-care team. Use of a simple flow chart can indicate if a patient is perhaps in need of review. Regular review of patient need prevents complications arising and prevents over-use, incorrect usage and even readmission. All too often nursing as a profession is reluctant to promote their usefulness, it is time to tell people what the nursing profession is worth and how cost effective it can be.
Conclusion As a result of use of the Key Messages, the majority of surgeries within the authors’ remit have since requested an audit of their stoma prescribing patterns. This has meant that the authors have been able to go into each surgery and discuss individual patient’s requirements in a way that ensures that the GP and pharmacist understand what the patient needs and why, quantities, what is essential and what can be ordered on an ‘as-required’ basis. Naturally, this has meant an increased workload but this can be done on a yearly basis so that any discrepancies can be picked up sooner. As mentioned previously there were also a number of cases of patients who required skin protectors for dermatological or incontinence problems rather than stoma care, but who had been accredited to the stoma care budget. Awareness of this discrepancy has helped surgeries to better align their budgets. Communication between the stoma team and local GPs has improved in that they are much more likely to bleep the team and ask for advice. It has also meant an increase in telephone calls from the delivery service regarding addition of accessories/products, but the stoma team have been able to ensure that inappropriate items have not been added that may have caused either damage to the patient’s skin or extra cost with no benefit. The team also gets a monthly list of what each patient is ordering; this highlights any excessive
© 2014 MA Healthcare Ltd
Table 3 was added as many dispensary assistants, district nurses etc., were unaware of some of the problems caused by the more commonplace medications and their effect on stoma output, so it was thought that a simple chart may be of use. Again this is offered as an ‘easy use’ guideline only. All of this work is relevant for any hospital with a stoma care input. GPs are unable to keep up to date with current
British Journal of Nursing, 2014, Vol 23, No 17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
PRESCRIBING ordering owing to leakages/inadequate adhesion of pouches or inappropriate stockpiling. The relationship between the stoma care team and the medicines management team, and also with local pharmacists and dispensaries has improved greatly, in that they feel more able to contact the team and approach them for advice. Excess stock returned to the team after patients have either had their stoma reversed, or if a patient has died, has decreased dramatically as patients have a better understanding of the cost involved in stockpiling. The review is not only about money, but also about evidence-based practice and achieving the best care for the patient, and hopefully the easy-to-use Key Messages will also achieve the best for each BJN individual patient.
KEY POINTS n The
‘Key Messages’ in this article are a guideline/tool only and each individual needs to be assessed on their own merit and has individual needs
n Taking
control of patient ordering ensures value for money for the service but also appropriate and correct care for the patient
n The
introduction of clinical commissioning groups is a new era and an opportunity for all stoma care services to promote their contribution to patient care and to establish new channels for multidisciplinary patient review
London. http://tinyurl.com/mk4m6hd (accessed 15th September 2014)
Elcoat C, Katte C, Morrisroe J et al (2010) High Impact Actions for Stoma Care. Colopast UK Ltd, Peterborough. http://tinyurl.com/nu5lchx (accessed 11 September 2014)
Conflict of interest: none Black P (2010) Professional promotion: Ensuring the value of stoma care services is recognized. Gastrointestinal Nursing 8(1): 27-30 Black P (2013) The role of accessory products in patients with a stoma. Br J Nurs 22(5): S24 Department of Health (2010) Equity and Excellence – liberating the NHS. DH,
Health and Social Care Information Centre (2014) Prescription Cost Analysis England 2013: Prescription items dispensed in the community in England and listed alphabetically within chemical entity by therapeutic class. 3 April. http://tinyurl.com/lnjysdh (accessed 17 September 2014) North J (2014) Early intervention, parastomal hernia and quality of life: a research study. Br J Nurs 23(5): S14-8
Orthopaedic Trauma Fares Haddad, Sam Oussedik, Rahul Patel n Designed to cover the basics of managing common orthopaedic and musculoskeletal injuries n Outlines a series of orthopaedic, musculoskeletal and trauma competencies
Orthopaedic Trauma: A Systematic Guide
n Intended to aid those involved in the initial assessment and management of patients to make the necessary fundamental and critical decisions
Edited by Fares Haddad, Sam Ous
sedik and Rahul Patel
n Specifically aimed at junior doctors and medical students n Chapters are based around a series published in the British Journal of Hospital Medicine; they are written by junior doctors but supervised by senior experts
© 2014 MA Healthcare Ltd
ISBN-13: 978-1-85642-248-2; ISBN-10: 1-85642-248-8; 234 x 156 mm; paperback; 260 pages; publication 2008; £24.99
Order your copies by visiting
www.quaybooks.co.uk
or call our Hotline
+44(0)1722 716 935
OrthopaedicCover.indd 1 30/3/07 14:50:45
British Journal of Nursing, 2014, Vol 23, No 17
S25
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
